COVID-19 Pre-Visit Screening Questionnaire

COVID-19 Pre-Visit Screening Questionnaire
In the recent matters relevant to COVID-19, we are setting precautionary measures to mitigate the spread of the virus for the benefit of our guests and patrons. In this regard, may we request you to answer a few questions prior to your appointment. Rest assured that all information we collect will be kept confidential and secure.
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Have you or a member of your household had any of the following symptoms in the last 21 days:
Yes No
Cough
Chills
Joint Pains and/or Body Aches
Shortness of Breath
Loss of Taste or Smell
Fever
Sore Throat
Have you or any member of your household been exposed to an individual who was tested positive to COVID-19 in the last 21 days?
YesNo
Have you or any member of your household been tested positive for COVID-19?
YesNo
Please provide details including date and other relevant information from the matter above
Have you or any member of your household traveled by commercial airline, ship, or any public transport in the last 21 days?
YesNo
If yes, please provide details of you tavel below:
Have you been tested for COVID-19 (i.e. antigen, swab)?
YesNo
Please provide details when was the test conducted and the result:
Have you been immunized with a COVID-19 vaccine?
YesNo
Please provide details below (i.e. # of dose, date, etc.)
By signing this form, I hereby declare that the information I provided above is true and correct to the best of my knowledge. I understand that I have the right to refuse my disclosure and I understand the purpose of this screening prior my appointment which is to mitigate and prevent the spread of the dreaded COVID-19 virus. I declare that I am of legal age and I voluntarily execute this screening questionnaire without representation or coercion.
Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

	Yes	No
Cough
Chills
Joint Pains and/or Body Aches
Shortness of Breath
Loss of Taste or Smell
Fever
Sore Throat